A nurse is caring for a client with acute glomerulonephritis. Which nursing intervention should be the highest priority?
1Encourage increased fluid intake to prevent dehydration
2Administer prescribed antibiotics to treat the underlying infection
3Provide a high-protein diet to replace protein lost in urine
4Monitor blood pressure and assess for signs of fluid overload✓ 정답
해설
Monitoring blood pressure and assessing for fluid overload is the highest priority because acute glomerulonephritis can lead to hypertension, heart failure, and pulmonary edema due to fluid retention. Other interventions are less immediate or not primary.
Core Nursing ExplanationKey Concept Analysis: This question tests the priority nursing intervention for a patient with Acute Glomerulonephritis (AGN). AGN is an inflammatory condition of the glomeruli (the kidney's filtering units), often following a streptococcal infection. The primary pathophysiological problem is decreased glomerular filtration rate (GFR), leading to sodium and water retention, hypertension, and potential for fluid overload. The priority in nursing care is always to address the most immediate threat to life and physiological stability.
Answer Rationale: Key Point! Option ④ is correct because hypertension and fluid overload are the most dangerous and immediate complications of AGN. The inflamed glomeruli cannot filter properly, causing fluid retention, increased blood volume, and elevated blood pressure. This can rapidly progress to hypertensive crisis, pulmonary edema, or heart failure (HF). Monitoring vital signs, especially blood pressure, and assessing for crackles in the lungs, edema, and weight gain are priority assessments to prevent these life-threatening complications.
Distractor Analysis:
Watch out for confusion! Option ① (Encourage increased fluid intake) is incorrect and potentially harmful. In AGN, the kidneys are retaining fluid, not losing it. Increasing fluid intake would exacerbate hypertension and fluid overload. Fluid restriction is often a key part of the medical management.
Option ② (Administer prescribed antibiotics) is a secondary intervention. While AGN is often post-streptococcal, the antibiotics treat the underlying infection to prevent further immune complex deposition, but they do not address the acute, life-threatening complications of the nephritic process itself. The inflammatory damage is already ongoing.
Option ③ (Provide a high-protein diet) is contraindicated. Proteinuria (protein in urine) is common in AGN, but a high-protein diet increases the workload on the damaged glomeruli. Management typically involves moderate protein restriction to reduce nitrogenous waste products that the kidneys are struggling to excrete.
Related Concepts: The nursing priorities in AGN follow the ABCs (Airway, Breathing, Circulation) and Maslow's hierarchy. Fluid overload directly threatens breathing (pulmonary edema) and circulation (hypertension, heart failure). Nursing care focuses on fluid balance management, monitoring for complications, administering antihypertensives and diuretics as ordered, and providing rest to reduce metabolic demands on the kidneys.
Concept Summary
Concept
Explanation in AGN
Primary Problem
Glomerular inflammation → ↓ GFR → Sodium/Water Retention
Priority Nursing: Monitor for fluid overload/hypertension
Priority Nursing: Monitor for infection, manage severe edema
Anatomy, Physiology & Pharmacology Points
Glomerulus Function: A network of capillaries where blood is filtered. Inflammation here impairs filtration, causing waste and fluid buildup.
Renin-Angiotensin-Aldosterone System (RAAS): Impaired kidney perfusion in AGN can activate RAAS, worsening hypertension and fluid retention.
Key Drugs in AGN: Antihypertensives (e.g., ACE inhibitors), Diuretics (e.g., furosemide) to manage hypertension/edema, and possibly antibiotics if active infection is present.
Memory Tips
AGN = "A Get Nasty" with Fluid: Think Acute GlomeruloNephritis causes nasty fluid retention and hypertension.
Priority = BP & Breath Sounds: Your top jobs are checking Blood Pressure and listening for crackles (sign of pulmonary edema).
Diet Don'ts: Remember the "3 No's" for AGN diet: NO extra fluids, NO high salt, NO high protein.
High-Frequency NCLEX Topics
NCLEX loves to test priority-setting in renal disorders. AGN is a classic scenario where the intuitive action (give fluids for a sick patient) is wrong, and you must choose the action that manages the complication (fluid overload) over treating the cause (infection). Be ready for questions that pit "monitor for complication" against "treat the underlying cause."
Watch Out for Question Variations!
Symptom Identification: "A child with AGN is admitted. Which finding requires immediate intervention?" (Answer: Blood pressure of 160/100 mmHg or severe headache).
Patient Education: "What is the most important instruction for a parent of a child with AGN?" (Answer: Report any swelling, decreased urine output, or headache).
Medication Administration: "The nurse is preparing to administer furosemide to a client with AGN. What is the primary purpose?" (Answer: To reduce fluid overload and hypertension).
Nursing Clinical Practice GuideClinical Scenario: You are caring for 8-year-old "Leo," admitted with periorbital edema, cola-colored urine, and a blood pressure of 148/92 mmHg. He had a sore throat two weeks ago. Diagnosis: Acute Post-Streptococcal Glomerulonephritis.
Nursing Intervention Strategy:
Assessment: Perform focused assessments every 4 hours (or per protocol): Vital signs (especially BP), daily weights on the same scale, strict I&O (Intake and Output), lung sounds (for crackles), and degree of edema. Assess for headache, visual disturbances, or seizures (signs of hypertensive encephalopathy).
Planning & Implementation: Collaborate to implement fluid and sodium restrictions. Administer antihypertensives and diuretics on time. Ensure bed rest during the acute phase to reduce cardiac workload and promote diuresis. Provide quiet, non-stimulating activities.
Patient/Family Education: Teach the family about the disease process, the reason for fluid/diet restrictions, and the importance of reporting increased edema, headache, or decreased urine output. Explain that full recovery is common in children but requires close follow-up.
Evaluation: Evaluate for decreased blood pressure, resolution of edema, increased urine output, and return of urine color to normal.
Patient Safety and Precautions: Key Point! Never force fluids. Weigh the patient daily at the same time, wearing similar clothing. A weight gain of 1 kg is approximately equal to 1 liter of fluid retention. Rapidly escalating hypertension is a medical emergency.
Nursing Procedure & Medication Flow
Blood Pressure Monitoring: Use the correct cuff size. Compare readings in both arms initially. Take readings with the patient quiet and rested.
Administering Diuretics (e.g., Furosemide): Give in the morning/early afternoon to prevent nocturia. Monitor for hypokalemia (muscle weakness, irregular pulse) and orthostatic hypotension. Monitor I&O closely after administration.
A Word from Your Senior Nurse
"In renal cases like AGN, your assessment skills are your superpower. That daily weight is not just a number—it's a direct measure of fluid balance. Listening to lung sounds isn't a routine task; it's how you catch pulmonary edema before the patient starts gasping for air. On the NCLEX and at the bedside, always ask yourself: 'What is the biggest threat to my patient right now?' For AGN, it's never the old infection—it's the fluid that's building up right now. Think like a detective of physiology!"
Acute Glomerulonephritis — An inflammatory condition of the glomeruli in the kidneys, often post-infectious, leading to hematuria, proteinuria, hypertension, and edema due to impaired filtration.
Glomerular Filtration Rate — The rate at which fluid is filtered through the glomerular capillaries into Bowman's capsule. A decreased GFR in AGN causes fluid and waste retention.
Fluid Overload — A condition where the body retains excessive fluid, leading to complications like hypertension, peripheral edema, and pulmonary edema. A primary concern in AGN.
Hypertensive Encephalopathy — A neurological emergency caused by severely elevated blood pressure, leading to cerebral edema. A critical complication to monitor for in AGN.
Post-Streptococcal Glomerulonephritis — The most common form of AGN in children, occurring 1-3 weeks after a Group A beta-hemolytic streptococcal infection (e.g., pharyngitis or impetigo).